Association Between State-Level Access to Reproductive Care and Suicide Rates Among Women of Reproductive Age in the United States
Authors: Jonathan Zandberg, Rebecca Waller, Elina Visoki, Ran Barzilay
Journal: JAMA Psychiatry (2022)

Importance Many states in the United States enforce restrictions to reproductive care, with access to abortion remaining a highly divisive issue. Denial of abortion is linked with heightened stress and anxiety among reproductive-aged women. However, no studies have tested whether access to reproductive care is linked to suicide. Objective To evaluate whether state-level restrictions in access to reproductive care in the United States were associated with suicide rates among reproductive-aged women from 1974 to 2016. Design, Setting, and Participants A longitudinal ecologic study with a difference-in-differences analysis assessed whether annual changes in the enforcement of state-level restrictions to reproductive care were related to annual state-level suicide rates vs rates of death due to motor vehicle crashes. Duration of follow-up varied between different states (range, 4-40 years), contingent on the first year that restrictions were implemented. Models controlled for year and state fixed effects and other relevant demographic and economic factors. Analyses were conducted between December 2021 and January 2022. Exposures Targeted Regulation of Abortion Providers (TRAP) laws index measuring state-year–level restrictions to reproductive care. Main Outcomes and Measures Annual state-level suicide rates and motor vehicle crash death rates among reproductive-aged women (ages 20-34 years; target group) vs women of postreproductive age (ages 45-64 years; control group). Results Twenty-one US states enforced at least 1 TRAP law between 1974 and 2016. Annual rates of death by suicide ranged from 1.4 to 25.6 per 100 000 women of reproductive age to 2.7 to 33.2 per 100 000 women of postreproductive age during the study period (1974-2016). Annual motor vehicle crash death rates among women of reproductive age ranged from 2.4 to 42.9 per 100 000. Enforcement of TRAP laws was associated with higher suicide rates among reproductive-aged women (β = 0.17; 95% CI, 0.03 to 0.32; P = .02) but not women of postreproductive age (β = 0.06; 95% CI, –0.11 to 0.24; P = .47) nor to deaths due to motor vehicle crashes (β = 0.03, 95% CI, –0.04 to 0.11; P = .36). Among reproductive-aged women, the weighted average annual-state level suicide death rate when no TRAP laws were enforced was 5.5 per 100 000. Enforcement of a TRAP law was associated with a 5.81% higher annual rate of suicide than in pre-enforcement years. Findings remained significant when using alternative, broader indices of reproductive care access and different age categorizations. Conclusions and Relevance In this study with a difference-in-differences analysis of US women, restrictions on access to reproductive care from 1974 to 2016 were associated with suicide rates among reproductive-aged women. Given the limitations of the ecologic design of this study, further research is needed to assess whether current factors affecting access to reproductive care services are related to suicide risk among women of reproductive age and to inform suicide prevention strategies.